MPs vote no on assisted dying – so what are the arguments for and against?

After a heartfelt and passionate debate in the House of Commons, MPs have voted 330 to 118 to reject the Assisted Dying Bill. As many as 85 MPs spoke, sharing personal stories and compelling arguments both for and against the bill, which proposed that a terminally ill person should be able to request assistance to end their own life.

The bill specified that for a person’s request to be granted, they must be terminally ill and “reasonably expected” to die within six months. Their decision would have had to be “voluntary, clear, settled and informed”, put forward in a written declaration signed by two doctors, and approved by a High Court judge. Only after a cooling off period of 14 days would a lethal drug have been prescribed.

Here, two experts in medical ethics sum up some of the arguments for and against the bill.

Arguments in favour

Hazel Biggs, professor of Healthcare Law at the University of Southampton

There are a number of arguments to be made in favour of the Assisted Dying Bill.

For one thing, the law should accommodate people who want to exercise their autonomy by being assisted to die, as long as they are capable of making that decision. We must be certain that any such decision has been well-considered and endured over a period of time. It’s crucial that the person making the decision has the capacity to do so, and that their choice is voluntary, and free from coercion. Such decisions must be made on the basis of clear, accurate and unbiased information about the prognosis, the alternatives available, the ways an assisted death might be brought about and what the patient might experience.

The Assisted Dying Bill included safeguards to ensure that all these criteria were met, and to protect those who might be vulnerable to exploitation or manipulation.

Currently, it is not unlawful to commit suicide, but assisting someone to commit suicide carries a maximum prison sentence of 14 years. In practice, if a loved one or carer assists someone to die, they are less likely to be prosecuted than someone operating in a professional capacity. That means that doctors and nurses, who could assist someone to die in a safe and reliable way, are more likely to be prosecuted. The concern here is that people may ask carers to help them because professional assistance is not available, which can end up in botched suicide attempts and result in greater suffering.

We also see people travelling to places where assisted suicide is lawful and available to foreign nationals, such as the DIGNITAS clinic in Switzerland. Anybody who helps someone travel to these places could be prosecuted. Around 200 people have travelled from the UK to use DIGNITAS. No one has faced prosecution so far, but a good and dignified death should ideally happen in familiar surroundings with loved ones close by. Forcing people to spend their final hours in a foreign land with limited contact with family and friends is inhumane.

The vote takes place.Stuck in Customs/Flickr, CC BY-NC-SA

Another problem with the status quo is that the law doesn’t come in to play until after the assisted suicide has taken place. As a result, those who might be vulnerable to being exploited or pressurised into an assisted suicide are only protected by the threat of criminal prosecution after the fact. If we regulated assisted suicide, we could make sure that no one was being pressured into suicide, that it really was their considered wish, and that they were competent to make that decision before any action was taken. This would provide greater protection than currently exists.

The sanctity of life is obviously a huge issue in this area. For medical professionals, the first imperative is to cure and sustain life. But the reality is that in some situations this is not possible anymore. Medicine is about caring, but it is not always about curing. It is about keeping people comfortable and making sure that they end their lives in a way that they would wish.

Palliative care can go some way towards providing this, and offers huge support to some patients. But it is not available to all and does not suit everybody. Sometimes the more caring option might be to give a person who wants it the choice of a properly regulated assisted suicide.

Reform of the law to permit assisted suicide would be safer for those who are vulnerable to exploitation and provide more choice for those who are terminally ill. It would remove barriers for those who wish to commit suicide but are physically incapable of so doing, and make it available to everybody who is eligible – not just those who can afford to join DIGNITAS and travel to Switzerland.

Arguments against

Charles Foster, research associate at the University of Oxford

The Assisted Dying Bill is dangerously misconceived. It is unnecessary: in all the circumstances envisaged by the bill, effective palliative care is readily available. It is simply wrong to claim – as some proponents of the bill do – that if the remedy of assisted suicide is not available, patients will die in pain or other distress.

Even if this were the case, the remedy is not to kill the patient, but to ensure that proper palliative care is available. If the bill becomes law, there will be less motivation to improve palliative care than there is currently. That is bad news for a far bigger cohort of patients than simply those who might consider assisted suicide.

The bill claims to ensure that no patient will consent to assisted suicide without fully understanding what they are asking for and without having the capacity to consent. But the safeguards on this front are inadequate. In fact, no imaginable safeguards would be adequate. The incidence of undiagnosed (but treatable) depression in terminally ill patients is very high.

So there is no reason to suppose that depression will always be diagnosed by the clinicians assessing those who request assistance to die. Depression often generates suicidal thoughts, which can evaporate with proper treatment. It can also compromise a patient’s capacity to make decisions – meaning that many of the assisted deaths would be of patients who have not fully, autonomously consented.

The bill also assumes that clinicians can be reasonably certain that a patient will die within six months. Medically speaking, the idea that such a prognosis can be in any way certain is ludicrous. Diseases don’t read medical textbooks.

Even when one can be certain that the patient is wholly capable and understands what they are asking for, there will very often be concerns about the patient’s motivation for asking to die. These worries are not addressed by the bill, and indeed cannot be addressed by any conceivable legislation. Vulnerable patients often feel that they are a burden – to relatives, to carers, to the healthcare system as a whole – and may ask to die in order to relieve others.

The way to deal with that concern is not to kill the patient: that implies that there is nothing wrong about the patient being made to feel that way. Hard though it may be, the ethos that generates the concern needs to be addressed.

Where doctors are permitted to assist suicide, all doctor-patient relationships are immediately and irretrievably changed. Imagine how you would feel if the doctor treating you for cancer came to your bedside having just helped to kill the patient in the next bed. It would mean that doctors were no longer simply healers, but accessories to killing. Doctors themselves have repeatedly and emphatically made it clear that they do not want that change. Assisted suicide denotes the failure of medicine: it is not a part of medicine. We can and should do better.

Charles Foster acted as counsel for the Society for the Protection of Unborn Children in the House of Lords case of Debbie Purdy, and for Care Not Killing in the Supreme Court case of Tony Nicklinson. Both cases concerned the law of assisted suicide.

Hazel Biggs does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.